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Clinical experience, performance in final
examinations, and learning style in medical
students: prospective study
I C McManus, P Richards, B C Winder and K A Sproston
BMJ 1998;316;345-350
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References
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Key messages
+ Children in hospital are often treated with
drugs not specifically licensed for use in
children (unlicensed), and drugs are also used
outside the terms of the product licence that
apply to indication, age, dose, or route of
administration (off label prescribing)
+ In this study 36% of children in 707 admissions
received drugs prescribed in either an
unlicensed or off label manner
+ Off label drug prescribing was more common
than unlicensed drug prescribing
+ All drugs used to treat children should be
subjected to the licensing process to ensure
their quality, safety, and efficacy
+ The Medicines Control Agency, the
pharmaceutical industry, and the NHS need to
address the issue of drugs being used in these
ways
Contributors: IC initiated and designed the study, supervised the
collection of data, analysed the data, and was involved in writing
the paper. ST designed the data collection forms, coordinated
and was involved in collecting and analysing the data, and was
involved in writing the paper. AJN initiated and was involved in
the design of the study, analysed the data, and was involved in
writing the paper. AL helped design the data collection form,
helped collect the data, and entered the data on to the computer.
Funding: North West Regional Health Authority.
Conflict of interest: None.
1
2
3
4
5
6
7
8
has established paediatric pharmacology research
units, which has resulted in an increase in the number
of clinical trials in children (S Yaffe, personal
communication, 1997). Each unit is led by an
experienced paediatric clinical pharmacologist. The
development of a similar approach in the United
Kingdom should be encouraged. The establishment of
a national centre to study drug treatment in children
would increase the number of clinical trials in which
children participate. Funding for such a centre should
be a priority for the British pharmaceutical industry,
the Medicines Control Agency, the NHS, and research
charities.
9
10
11
12
13
14
Choonara I, Nunn T, Hull D. Medicines for children. J Pharm Med
1995;5:96.
British Paediatric Association and the Association of the British Pharmaceutical Industry. Licensing medicines for children. Joint report of the British
Paediatric Association and the Association of the British Pharmaceutical Industry, 1996. London: BPA, 1996.
Turner S, Nunn AJ, Choonara I. Unlicensed drug use in children in the
UK. Paediatr Perinat Drug Ther 1997;1:52-5.
Nahata MC. Licensing of medicines for children in the USA. Paediatr
Perinat Drug Ther 1997;1:50-1.
Cotè CJ, Kauffman RE, Troendle GJ, Lambert GH. Is the “therapeutic
orphan” about to be adopted? Pediatrics 1996;98:118-23.
Turner S, Gill A, Nunn T, Hewitt B, Choonara I. Use of “off-label” and
unlicensed drugs in paediatric intensive care unit. Lancet 1996;347:
549-50.
Association of the British Pharmaceutical Industry. ABPI data sheet
compendium 1995-96. London: Datapharm Publications, 1995.
British Medical Association and the Royal Pharmaceutical Society of
Great Britain. British national formulary. No 31. London: BMA, RPSGB,
1996.
Kauffman RE. Status of drug approval processes and regulation of medications for children. Curr Opinion Pediatr 1995;7:195-8.
Cotè CJ. Sedation for procedures in children. Paediatr Perinat Drug Ther
1997;1:3-8.
European Agency for the Evaluation of Medicinal Products. Note for guidance on clinical investigation of medicinal products in children. London:
EAEMP, 1997.
Cornelissen EAM, Kollee LAA, De Abreu RA, Motohara K, Monnens
LAH. Effects of oral and intramuscular vitamin K prophylaxis on vitamin
K1, PIVKA-II and clotting factors in breast fed infants. Arch Dis Child
1992;67:1250-4.
Benini F, Johnston C, Faucher D, Aranda JV. Topical anesthesia during
circumcision in newborn infants. JAMA 1993;270:850-3.
Parkinson L, Hughes J, Gill A, Billingham I, Ratcliffe J, Choonara I. A
randomised controlled trial of sedation in the critically ill. Pediatr Anesth
1997;7:405-10.
(Accepted 23 September 1997)
Clinical experience, performance in final examinations,
and learning style in medical students: prospective study
I C McManus, P Richards, B C Winder, K A Sproston
Abstract
Objective: To assess whether the clinical experience
of undergraduate medical students relates to their
performance in final examinations and whether
learning styles relate either to final examination
performance or to the extent of clinical experience.
Design: Prospective, longitudinal study of two cohorts
of medical students assessed by questionnaire at time
of application to medical school and by questionnaire
and university examination at the end of their final
clinical year.
Subjects: Two cohorts of students who had applied to
St Mary’s Hospital Medical School during 1980
(n = 1478) and 1985 (n = 2399) for admission in 1981
and 1986 respectively. Students in these cohorts who
entered any medical school in the United Kingdom
were followed up in their final clinical year in 1986-7
and 1991-2.
BMJ VOLUME 316
31 JANUARY 1998
Main outcome measures: Students’ clinical
experience of a range of acute medical conditions,
surgical operations, and practical procedures as
assessed by questionnaire in the final year, and final
examination results for the students taking their
examinations at the University of London.
Results: Success in the final examination was not
related to a student’s clinical experiences. The amount
of knowledge gained from clinical experience was,
however, related to strategic and deep learning styles
both in the final year and also at the time of
application, five or six years earlier. Grades in A level
examinations did not relate either to study habits or
to clinical experience. Success in the final examination
was also related to a strategic or deep learning style in
the final year (although not at time of entry to medical
school).
Conclusions: The lack of correlation between
examination performance and clinical experience
Academic
Department of
Psychiatry, Imperial
College School of
Medicine at St
Mary’s, London
W2 1PG
I C McManus,
professor of psychology
and medical
education
B C Winder,
research coordinator
K A Sproston,
research assistant
continued over
BMJ 1998;316:345–50
345
Papers
Northwick Park and
St Mark’s Trust,
Northwick Park
Hospital, Harrow
HA1 3UJ
P Richards,
medical director
Correspondence to:
Professor I C
McManus, Centre
for Health
Informatics and
Multiprofessional
Education,
University College
London Medical
School, London
N19 5NF
i.mcmanus@
ucl.ac.uk
Downloaded from bmj.com on 12 June 2006
final year of undergraduate training in the United
calls into question the validity of final examinations.
Kingdom confirmed that there were large individual
How much knowledge is gained from clinical
differences in clinical experience as well as secular
experience as a student is able to be predicted from
trends and regional differences.12
measures of study habits made at the time of
application to medical school, some six years earlier,
A levels and other secondary school examinations
although not from results of A level examinations.
are comparatively poor predictors of students’ success
Medical schools wishing to select students who will
at university.13 Better predictors are students’
gain the most knowledge from clinical experience
approaches to their work, or their study habits and
cannot use the results of A level examinations alone
learning styles.14 15 The skills needed to do well at A
but could assess a student’s learning style.
level are less sophisticated than the critical analytical
skills that universities instil, and the higher correlation
between entry qualifications and final grades in science
Introduction
and medicine than in other university subjects13
“To study the phenomena of disease without books
suggests an undue emphasis on factual recall rather
is to sail an uncharted sea, while to study books
than deeper cognitive analysis. Universities generally
without patients is not to go to sea at all.”
value deep learning (table 1) that is motivated by a
1
Sir William Osler
desire for personal understanding and vocational
relevance and demonstrated by the student’s searching
Medical training—and particularly British medical
for principles and the integration of knowledge across
2–5
training —has always emphasised not merely learning
different domains. In contrast, surface learning is motifrom textbooks but also gaining experience directly
vated principally by fear of failure and is dominated by
from patients themselves. Although clinical experience
rote learning for regurgitation in examinations and is
is perceived as central to medical education, there has
followed by forgetting. Strategic learning is motivated
been little assessment of how and why medical students
by a desire for success and by competition with other
differ in the knowledge they gain from clinical
students. In strategic learning students use whichever
experience and how clinical experience relates to sucmethod—deep or surface learning—is more appropri6
cess in clinical examinations. Educational theory
ate
for a particular topic; the result is patchy
predicts that clinical experience and examination sucunderstanding
and a lack of integration across topics.
7
cess should both relate to study habits. There are large
Empirically, deep and strategic learning styles predict
variations between students in the amount and range
success in final examinations at university, whereas surof their experience,8 9 and differences also occur in
face learning predicts failure.15 16
10 11
postgraduate training.
Comparison of entry
This paper assesses the relation between clinical
cohorts of medical students in 1981 and 1986 in their
experience, examination success, and study habits in
two cohorts of medical students.
Table 1 Summary of the differences in motivation and study process in surface, deep,
and strategic learning
Learning style
Motivation
Process
Surface
Completion of course
Fear of failure
Rote learning of facts and ideas
Focus on discrete task components
Little real interest in content
Deep
Interest in subject
Vocational relevance
Personal understanding
Relate ideas to evidence
Integrate material across courses
Identify general principles
Strategic
To achieve high grades
To compete with others
To be successful
Use techniques that achieve highest grades
Patchy and variable understanding
1980 (1985) Survey of all applicants
to St Mary's Hospital Medical School
Applicants' questionnaire, which included
measures of study habits, sent to all
applicants with postal addresses in the
United Kingdom (European Community)
85% (93%) response rate
1981 (1986): 517 (871) students admitted
to medical schools in the United Kingdom
1986-7 (1991-2): 463 (761) students
in their final year at medical schools
in the United Kingdom
Final year questionnaire, which included
questions on clinical experience and study
habits, sent to all final year students;
65% (51%) response rate
Detailed final examination results collected for
all 330 (361) students taking final examination
of the University of London
Fig 1 Study design for survey of learning styles and clinical experience in two cohorts of
medical students in 1981 (1986)
346
Subjects and methods
Study design—This study began as two surveys of medical student selection and assessed applicants who had
applied for admission to St Mary’s Hospital Medical
School in 198117 and 1986 (fig 1).18 All applicants with
addresses in the United Kingdom in the first study and
addresses in the European Community in the second
study were sent a questionnaire which included measures of study habits; there was a response rate of 85%
(1151/1362) in the first study and 92% (2043/2209) in
the second. Of the 1478 applicants in the first study,
517 were admitted to medical schools in the United
Kingdom. Of the 2399 applicants in the second study,
871 were admitted to medical schools in the United
Kingdom. In 1986-7, 463 final year students from the
first cohort were sent a second questionnaire, as were
761 from the second in 1991-2; the questionnaire
measured study habits and clinical experience, and the
response rate was 65% (301/461) for the first study and
50% (383/766) for the second.
Study habits and learning styles—Members of the two
cohorts received an abbreviated 18 item study process
questionnaire developed by Biggs19–22 which assesses
learning styles on surface, deep, and strategic scales.7
Reliability coefficients (á) were 0.535, 0.737, and 0.703
in final year students in the first study and 0.567, 0.715,
and 0.701 for final year students in the second study.
For applicants in 1986 the reliability coefficients were
0.556, 0.713, and 0.647. Applicants in 1981 were
BMJ VOLUME 316
31 JANUARY 1998
Papers
Clinical experience
Downloaded from bmj.com on 12 June 2006
assessed on the less reliable measure of syllabus220
boundness23 (á = 0.497).
Performance in final examinations—Altogether, 330 of
210
the students in the first cohort and 361 of those in the
second took final examinations at the University of
200
London. Detailed information was obtained from
190
records in the faculty of medicine. The examination
had five separate sections (medicine, which included
180
psychiatry, paediatrics, and public health; surgery;
pathology; clinical pharmacology; and obstetrics and
170
gynaecology), all of which had multiple choice and
160
essay questions. All subjects except pathology had an
oral examination (viva voce), and all except clinical
150
pharmacology had a practical or clinical examination
or both. Principal component analysis, based on a can140
didate’s individual scores, was used to calculate a single
130
measure of performance, the overall finals score (first
cohort: á = 0.879; second cohort: á = 0.868).24 Addi120
tionally, scores were calculated for the five separate
subjects and the four modes of assessment (multiple
110
50
60
70
80
90
100 110 120 130 140 150
choice question, essay, oral, and clinical and practical
Performance in final examination
examinations).24
Clinical experience—Students in the first cohort
Fig 2 Association between performance in final examination and
total amount of clinical experience in 1986 cohort (r=−0.024,
reported their experience of 15 acute medical
P=0.75). The measure of clinical experience12 comprised 20 items
conditions and those in the second cohort of 20 condiscored 1 to 3 and 47 items scored 1 to 4 (total possible range 67 to
tions. Students in each cohort reported their
230). Performance in the final examination was the principal
experience of 18 surgical operations. Students in the
component of the examinations, scaled to have a mean of 100 and a
standard deviation of 15
first cohort reported their experience of 17 practical
procedures, and those in the second cohort reported
their experience of 29 practical procedures. Scores on
the 50 items in the first cohort and 67 in the second
expected directions. The pattern was similar for differwere combined into a single total experience score
ent subjects and examination methods. Although study
12
(first cohort: á = 0.861; second cohort: á = 0.907).
habits in the final year predicted performance in the
final examination in the 1986 cohort (n = 344) there
Results
were non-significant correlations between examination
performance and surface, deep, and strategic processClinical experience and final examination
ing as assessed at the time of application (r = − 0.068,
performance
P = 0.21; r = 0.031, P = 0.57; r = − 0.004, P = 0.94).
The correlation between overall performance in final
Similarly,
syllabus-boundness at time of application in
examinations and total clinical experience was not sigthe 1981 cohort (n = 285) showed a non-significant
nificant (first cohort: r = 0.048, P = 0.48, n = 215;
correlation
with
examination
performance
second cohort: r = − 0.024, P = 0.75, n = 176) (fig 2).
(r = − 0.007, P = 0.90).
There was no evidence of specific associations. There
Measures of surface, deep, and strategic learning at
were non-significant correlations between experience
application and in the final year were correlated in the
of treating medical conditions and performance on the
1986 cohort (n = 361) (r = 0.420, r = 0.370, r = 0.336
medicine section of the final examination (first cohort:
(all P < .001)), confirming moderate long term trait star = − 0.041, P = 0.55; second cohort: r = − 0.059,
bility. Syllabus-boundness at time of application in the
P = 0.44); between surgical operations seen and
1981 cohort (n = 307) correlated with final year
performance in the surgery examination (first cohort:
r = 0.088, P = 0.20; second cohort: r = − 0.118,
surface, deep, and strategic learning (r = 0.205,
P = 0.12); and between overall experience and perP < 0.001; r = − 0.175, P = 0.002 ; r = − 0.039, P = 0.49),
formance in clinical examinations (first cohort:
confirming construct overlap of syllabus-boundness
r = 0.026, P = 0.70; second cohort: r = − 0.042,
and learning style.
P = 0.58). These results suggest that clinical experience
does not influence performance in final examinations.
Study habits and clinical experience
Table 2 shows the correlation of clinical experience
Study habits and performance in final examination
and study habits assessed both in the final year and at
Study habits in the final year predicted overall examinthe time of application. Students with higher scores on
ation performance; the correlations with surface, deep,
deep and strategic learning show significantly higher
and strategic learning in the first cohort (n = 213) were
levels of overall experience (fig 3) whether study habits
r = − 0.204 (P = 0.003), r = 0.157 (P = 0.022), and
are measured in the final year or at the time of
r = 0.178 (P = 0.009) respectively and in the second
selection—five or six years earlier. Surface learning
cohort (n = 171) r = − 0.081 (P = 0.28), r = 0.235
(and syllabus-boundness) scores at application showed
(P = 0.002), and r = 0.266 (P < 0.001). The negative
significant negative correlations with clinical
associations with surface learning and positive associations with deep and strategic learning were in the
experience.
BMJ VOLUME 316
31 JANUARY 1998
347
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Clinical experience
Downloaded from bmj.com on 12 June 2006
Non-respondents
Table 2 Correlation (r) between amount of clinical experience
A potential risk in a study in which only 51% of
and measures of study habits assessed at time of application
students in the first cohort and 65% in the second
and in final year in 1981 and 1986 cohorts
replied to the questionnaire during their final year is
At application
In final year
that respondents may represent a biased subset of
1981 cohort
those in the initial study. In the initial study, however,
No of respondents
311
333
this bias is unlikely to be a serious problem since
Syllabus-boundness
−0.134*
NE
response rates were satisfactory at 85% and 93%
Surface learning
NE
−0.073
respectively. We assessed possible bias by comparing
Deep learning
NE
0.212***
baseline measures and the final examination performStrategic learning
NE
0.206***
ance of those who did and those who did not return
1986 cohort
our questionnaire during their final year. In neither
No of respondents
363
375
cohort were there significant differences between
Surface learning
−0.140**
−0.054
Deep learning
0.262***
0.136**
respondents and non-respondents in the final year in
Strategic learning
0.220***
0.213***
terms of study habits at the time of selection, final year
*P<0.05; **P<0.01; ***P<0.001.
examination performance, or in mean grade at O level,
NE=Not evaluated.
and number of O and A levels taken. In the 1981
cohort the non-respondents had slightly lower mean
grades at A level (3.81 (SD 0.77), n = 177 v 3.98 (0.78),
220
t = 2.44, df = 513, P = 0.015); the effect was not
210
significant in the 1986 cohort (4.16 (0.741), n = 377 v
4.19 (0.64), t = 0.67, df = 513, P = 0.051). Our respond200
ents were probably a representative sample of the stu190
dents as a whole.
180
170
Discussion
160
150
140
130
120
110
100
90
80
5
10
15
20
25
30
35
Deep learning score on application
Fig 3 Association between total amount of clinical experience and
score on Biggs’s measure of deep learning in applicants in the 1986
cohort (r=0.262, P<0.001). Clinical experience measured as in fig 2
A level examinations
Grades at A level are a potential confounder of the
associations reported here. Mean A level grade17 18
showed a significant correlation with performance in
final examinations (first cohort: r = 0.336, P < 0.001,
n = 329; second cohort: r = 0.281, P < 0.001, n = 359);
these values are compatible with those reported
elsewhere.25 26 However, grades at A level showed
almost no association with syllabus-boundness in the
1981 cohort (r = 0.047, P = 0.12, n = 1104) and with
surface, deep, and strategic learning at the time of
selection in the second cohort (r = − 0.021, P = 0.34;
r = − 0.051, P = 0.024; r = 0.024, P = 0.29; n = 1932,
NS). There was no correlation with learning styles in
the final year (first cohort (n = 333): r = − 0.076,
P = 0.26 for surface learning; r = 0.080, P = 0.15 for
deep learning; r = 0.099, P = 0.07 for strategic learning;
second cohort (n = 371): r = 0.091, P = 0.080;
r = -0.005, P = 0.93; r = 0.003, P = 0.96); grades at A
level did not correlate with clinical experience (first
cohort: r = 0.023, P = 0.68, n = 335; second cohort:
r = − 0.034, P = 0.51, n = 370).
348
Medical students work hard to acquire clinical
experience.27 If clinical problem solving is the key to
learning for medical students and doctors,28 potential
doctors should see many patients and medical students
with clinical experience should be seen to benefit from
it, not least by performing better in clinical examinations. If clinical experience is educationally desirable
then students who are likely to learn most from
their contact with patients should be selected to study
medicine.
Validity of final examinations
Our study shows that students with more clinical
experience do not do better in final examinations
either generally or specifically in the clinical sections of
examinations. This conclusion is robust, being found in
two cohorts of reasonable size studied five years apart.
We do not believe our results reflect any specific failing
of the University of London’s examinations, which are
typical of those in most medical schools in the United
Kingdom and have external examiners at all levels. We
also recognise that the radical educational and curricular changes being introduced into medical schools
since the publication of Tomorrow’s Doctors by the General Medical Council29 may invalidate our findings for
future generations of medical students. That, however,
is an empirically testable hypothesis, and our current
study provides the baseline data needed for assessing
the reforms.
The lack of correlation between the amount of
clinical experience and performance in final examinations calls into question the clinical validity of the
examinations; our conclusions may also apply to similarly structured postgraduate examinations. Examinations may be failing to assess the skills and knowledge
acquired directly from clinical experience, such as
carrying out practical procedures, communicating with
patients, formulating differential diagnoses, ordering
tests, evaluating their results, and deciding on manageBMJ VOLUME 316
31 JANUARY 1998
Papers
Downloaded from bmj.com on 12 June 2006
throughout a professional career—is a characteristic that
Key messages
can be identified at the time of selection. However, selection of medical students is based primarily on the results
+ Medical students with the most clinical
of examinations that do not correlate with the learning
experience do not perform best in final
styles that are desirable in medical students, and these
undergraduate examinations, throwing some
examinations do not predict the successful acquisition of
doubt on the validity of the examinations
clinical experience. The implication is that the greater
+ The amount of knowledge a student gains from
the dependence of a selection system on grades at A
clinical experience correlates positively with
level the more limited is its capacity for selecting doctors
deep and strategic learning styles as measured
who will gain the most knowledge from clinical
not only in the final year but also at the time of
experience and therefore probably continue to benefit
selection, five or six years earlier
from clinical experience throughout their careers.29
+ If it is important for students to obtain as much
Evaluation of the effectiveness of medical training
clinical experience as possible then final
should concentrate on characteristics other than the
examinations require restructuring to assess
ability to pass examinations, both as an input measure
and reward clinical experience, and selection
for selection and as an output measure of the quality of
should emphasise deep learning which cannot
medical education.
be assessed from grades at A level
+ The use of deep and strategic learning styles in
the final year of medical school predicts better
performance in the final examination, but the
same measures at the time of selection for
admission to medical school do not predict
examination performance
ment. An alternative possibility is that students are failing to learn properly from their experience since
“[clinical] experience without training increases confidence not competence.”30 31 Whatever the mechanism,
it must be a concern that examinations send the wrong
messages to undergraduates. Assessments determine
what and how students choose to study. If skills and
experiences acquired from patients are not seen to be
relevant to success in examinations then fear of failure
will drive some students to ignore clinical experience
and resort instead to what is perceived as the real
curriculum—that is, the information contained in textbooks. These attitudes seem unlikely to encourage the
lifelong learning necessary for doctors, or to foster the
development of “reflective practitioner[s]”32 who can
modify their practice in relation to experience.
Since strategic and deep learning styles correlate
positively with performance in final examinations and
surface learning correlates negatively, the present
examinations are probably encouraging a deeper
understanding of medicine and medical practice. That
other studies have failed to find this probably indicates
that they had too small a sample size.33 That study habits
at the time of selection for admission to medical school
did not predict results in final examinations reflects the
fact that study habits are states as much as traits. There is
a well documented trend towards surface learning in
conventional medical education,34 35 a process driven in
part by failure in previous examinations.36 Courses
structured less conventionally, perhaps using problem
based learning,34 35 may find a correlation between study
habits at entry and performance in final examinations.
Clinical experience and study habits
An important finding of this study is that the knowledge
acquired by a clinical student can be predicted from the
learning style measured at the time of application to
medical school—half a decade earlier. This implies that
the acquisition of knowledge from clinical experience—
and the ability to continue to gain experience
BMJ VOLUME 316
31 JANUARY 1998
We thank the Faculty of Medicine of the University of London
for permission to analyse the examination results of
undergraduates, and we thank our many respondents for completing our questionnaires.
Contributors: ICM and PR initiated and designed the cohort
studies; ICM was responsible for management of the studies and
for statistical analysis; BCW coordinated the acquisition and
processing of the data; KAS and BCW collected much of the
data; the manuscript was written by ICM and PR with help from
BCW and KAS. ICM is guarantor for this paper.
Funding: The survey of the 1981 cohort was funded by the
Economic and Social Research Council, and the survey of the
1986 cohort by the Economic and Social Research Council and
the Leverhulme Trust.
Conflict of interest: None.
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(Accepted 5 August 1997)
Home sampling versus conventional contact tracing for
detecting Chlamydia trachomatis infection in male partners
of infected women: randomised study
Berit Andersen, Lars Østergaard, Jens K Møller, Frede Olesen
See p 351
Research Unit and
Department of
General Practice,
University of
Aarhus, DK-8000
Aarhus C, Denmark
Berit Andersen,
research assistant
Frede Olesen,
consultant physician
Aarhus University
Hospital, DK-8000
Aarhus C
Lars Østergaard,
senior registrar of
infectious diseases
Jens K Møller,
director of clinical
microbiology
Correspondence to:
Dr Andersen
ba@alm.aau.dk
BMJ 1998;316:350–1
350
Urogenital infections with Chlamydia trachomatis are
widespread and usually asymptomatic. Major complications from infection include ectopic pregnancies and
female infertility.1 Although contact tracing reduces the
prevalence of chlamydia infection,2 the test rate among
partners is often low, partly because male contacts have
to have a urethral swab taken by a doctor.
As the polymerase chain reaction can successfully
detect infection in urine samples,3 we investigated
whether the test rate could be increased by asking the
male contacts of infected women to send a urine sample directly from home to a laboratory instead of having a doctor take a urethral swab.
Subjects, methods, and results
Ninety six women with C trachomatis infection seen in
general practices in Aarhus County, Denmark, were
randomly divided according to their date of birth into
an intervention group (45 patients) and a control
group (51 patients). Women in the intervention group
were asked to complete a questionnaire, including the
number of male sexual partners over the preceding six
months, and to supply their partners with an envelope
containing a 10 ml sterile container, information on
collecting the first urine sample of the morning, and a
prepaid envelope for returning the sample to the laboratory at the Aarhus University Hospital. Envelopes
supplied by the control group contained a request for
the partner to visit his doctor as well as a contact slip
and a prepaid envelope to be given to the doctor for
returning a urethral swab sample.
Swab samples were examined by enzyme immunoassay (MicroTrak II, Behring, Germany). Specimens
with an optical density greater than 30% of the recommended cut off point were confirmed by polymerase
chain reaction assay (Amplicor, Roche, Switzerland).4
Urine samples were analysed by the same polymerase
chain reaction. A sample was considered positive only
if the result was confirmed on retesting.
The table shows the results of contact tracing. Forty
four out of 65 (68%) partners were examined in the
intervention group compared with 19 out of 68 (28%)
in the control group (÷2 = 19.50; P < 0.01). The
difference in test rate was 0.4 (0.68 minus 0.28) (95%
confidence interval 0.24 to 0.56). Although not
significant, there were more new cases of C trachomatis
per index case in the intervention group (0.27) than in
the control group (0.14). The difference between the
two groups was 0.13 ( − 0.03 to 0.29). Furthermore,
there was a trend for partners of women in the
intervention group to be tested earlier than those of
women in the control group, with a mean delay time of
12.6 days and 17.7 days respectively. Thus the
difference between the two groups was 5.1 days ( − 1.6
to 11.8). The prevalence of C trachomatis in samples
from the intervention and control groups was 27% and
39% respectively.
Tracing of male contacts of women with Chlamydia trachomatis
infection
Intervention
group (n=45)
Control group
(n=51)
No
65
68
Median No per index case
1
1
Mean No per index case
1.44
1.33
Range
0-4
0-4
Partners contacted
Partners tested
No (% of those contacted)
44 (68)
19 (28)*
Mean No per index case
0.98
0.37
Range
0-3
0-1
No (% of those tested)
12(27)
7(39)
Mean No per index case
0.27
0.14
12.6
17.7
Partners infected
Time until testing
Mean delay (days)
*Result unknown for one partner.
BMJ VOLUME 316
31 JANUARY 1998